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Skip (Sin Hoon) Lam, Director of Pharmacy, Peninsula Health, VIC delivered this presentation at the 2013 Electronic Medication Management conference. It is Australia’s only conference to look solely at electronic prescribing and electronic medication management systems. For more information on the annual event, please visit the conference website: http://www.healthcareconferences.com.au/emedmanagement
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Implementing & Developing the Cerner Millenium Clinical System
Integration and Communication between systems
Skip LamDirector of PharmacyPeninsula Health
• All major disciplines• In 2011/12,
• 79,311 ED attendances• 74,664 patients admitted• 73,030 community mental health occasions of care were provided
Peninsula Health
Strategic focus
Will the doctors use it?
0
2000
4000
6000
8000
10000
12000
Num
ber o
f Ite
ms
Jul-02
Aug-02Sep-02Oct-0
2Nov-02Dec-02Jan-03Feb-03Mar-0
3Apr-0
3May-03Jun-03
Jul-03
Aug-03Sep-03Oct-0
3Nov-03Dec-03Jan-04Feb-04Mar-0
4Apr-0
4May-04Jun-04
Jul-04
Aug-04Sep-04Oct-0
4Nov-04Dec-04Jan-05Feb-05Mar-0
5Apr-0
5May-05Jun-05
Jul-05
Aug-05Sep-05Oct-0
5Nov-05Dec-05Jan-06Feb-06Mar-0
6Apr-0
6May-06Jun-06
Number of drugs e‐prescribed/month July 2002‐ June 2006
Introduction of PBS
ProgressSep 2009 – Project commencesJun 2011 – Nov 2011Discharge prescribing implemented for all sites (600 beds) Jun 2012Inpatient prescribing/administration at rehabilitation sites (120 beds)Aug 2012Inpatient prescribing/administration at acute mental health wards (60 beds)Nov 2012General medical wards (75 beds), CCU (15 beds), AMU (15 beds), Transit Ward (15 beds), Acute Mental Health (45 beds)Radiology/Pathology, ICU (13 beds)PharmacyFeb 2013EDMay or Jun 2013General surgical wards
Dr: Obtain new chartHandwrite ordersNotify ward clerk/RN
Nurse obtain drug from imprest cupboard orNurse orders non‐imprest orPharmacist walk to bed, checks chart or take note to supply
Nurse reviews chart to find orders for administration
Chart kept at end of bed
Drugs kept at end of bed
Dr: Create e‐Orders
Notify ward clerk/RN if urgent
Nurse obtain drug from imprestcupboard orNurse orders non‐imprest orPharmacist runs report or check PharmNET to verify/supply
Nurse reviews task listNurse barcode wrist band/not drugsAdminister via e‐MAR
Drugs kept at end of bed
Medication Reconciliation
Medication History Documentation
As clinical documentation is still mainly on paper, medication reconciliation data elements are documented in various places
• Document Medication by Hx tab under Medications tab in Cerner
• Clinical System additional notes page ‐ paper• Alerts tab in Cerner• Allergy on Cerner
Populated from previous episode
(1) Source 1 & 2 together on form. Cerner only prints source 1. If enter source 2 into comments, will appears under comments.
(2) Reconcile after printing
Type in vaccination details as will appear in
future re‐admits.
Pharmacy Specific Alerts
• Peninsula Alerts Medical/Clinical – Drug Addiction Therapy– Impairment ‐ Hearing– Impairment ‐ swallowing difficulty– Impairment ‐ Vision– Medical ‐ Patient on Clozapine– Meds ‐ Dose Administration Aid used– Meds ‐ History of Poor Compliance– Pharmacy (only alert recorded not change banner bar)
Pharmacy Specific Alerts
• Peninsula Alerts Safety – Safety – Alcohol Abuse– Safety – Smoking (i.e. current smoker)– Safety – Drug Abuse (can add information into comments e.g. marijuana, opioid abuser etc)
Medication reconciliationClinician (usually pharmacist) document medication history
Dr interviews patient and uses admission reconciliation to create drug chart
Dr use discharge reconciliation to create prescription
Clinical documentation on paper still existsPharmacist unable to interview patient early in the admission
Dr use discharge reconciliation from medication history and inpatient orders to create prescription
Dr e‐prescribed from scratch
Preferred Option for Pharmacy
DispensingInventory Control
PurchasingPBS ClaimReports
Prescribe in Cerner Powerchart
Clinical review & product assignment in Cerner’s
PharmNet e‐Rx
Imprest Information
Decisio
n supp
ort iPharmacy
X
Business Requirements• Setup an interface between Cerner and iPharmacy to receive & process standard prescription orders (PBS and non‐PBS)
• Complex orders (e.g. orders containing a combination of ingredients) NOT in scope
• Only unidirectional interface from Cerner to iPharmacy
• Use of the Australian Medicines Terminology
The Hard Yards
• Product design and specification• Mapping doctors in Cerner® to iPharmacy®• Mapping cost centres in Cerner® to iPharmacy®• Product assignment in iPharmacy using TPP codes• Mapping unit of measures (UOM) in iPharmacy® to
Cerner®• Purge eRx orders• Not ONE interface! Local integration specialist
HealthSmart Clinical System
CernerPowerchart
CernerPharmNet
iPharmacy
Control Parameters• Generics (Domain)• Location (Local)• Order sentences (Local)
Verification of orders must include product assignment (Domain).
Non‐imprest items sent to iPharmacy
Clinical Pharmacists’ Priorities
1. Discharge prescriptions2. Ward rounds when available. 3. Review and verify orders that come up on PharmNet ‐
while doing this also review those patients' drug charts.
4. Follow up issues identified from previous days, or based on blood test results or on high risk drugs, vancomycin, digoxin, warfarin, etc.
5. Interview patients and perform medication reconciliation
6. Review drug charts
Criteria for Autoverification• Minor and Moderate interactions will autoverify• Low risk drugs which have been set to autoverify either at the drug or sentence level• Order sentences that has NOT been modified at the point of ordering• Prescribed drugs that are modified • Cancelled/Discontinued orders• Orders which do not auto product assign• Product assignment will fail if the order requires more than 3 dose units of a product (e.g. more than 3 tablets) to fulfil the ordered dose. This is intended to be a safety feature of PharmNet.
Impact of Increased Clinical Pharmacy Activities Cjeng T Toh, Skip S Lam, Benjamin K Leung. Journal of Pharmacy Practice and Research Volume 35, No. 2, 2005
Impact of an Emergency Department Pharmacist on Prescribing Errors in an Australian HospitalJan‐Marie deClifford, Frances M Caplygin, Skip S Lam, Benjamin K Leung. Journal of Pharmacy Practice and Research Volume 37, No. 4, 2007
Evaluation of a Pharmacist‐Initiated E‐Script Transcription Service for Discharged Patients Jan‐Marie deClifford, Skip S Lam, Benjamin K Leung. Journal of Pharmacy Practice and Research Volume 39, No. 4, 2009
Australian Medicines Terminology
The Australian Medicines Terminology (AMT) is the national terminology to identify medicines used in Australia, using unique codes to deliver unambiguous, accurate and standardised names for both branded (trade) and generic (medicinal) products.
Benefits•Reduces errors by the use of clear, standard and unambiguous naming.•Enables the safe and reliable exchange of medicines information•Facilitates effective decision support of active ingredients to assist with drug allergy and drug interaction checking.•Supports good clinical practice by allowing linkage of data such as clinical guidelines and dosing information.
Cerner Multum
• Multum provides a foundational database with comprehensive drug product and disease nomenclature information to link with Multum's clinical information systems and other outside systems. This database includes drug names, drug product information, disease names, coding systems such as ICD‐9‐CM and NDC, generic names, brand names and common abbreviations.
C‐dispensables
Primary Brand
NM
Z
Y
Multum synonyms map to AMT
Renaming examplesBefore After renaming
Monopril 10 mg tablet; uncoated Monopril 10 mg tablet
cephalexin 250 mg/5 mL oral liquid: powder for
cephalexin 250 mg/5 mL oral liquid
Xalatan (latanoprost 0.1% (1 mg/mL)) eyedrops: solution
Xalatan 0.1% eye drops
Chlorvescent (potassium chloride 595 mg (7.97 mmol potassium) + potassium bicarbonate 384 mg (3.84 mmolpotassium) + potassium carbonate 152 mg (2.2 mmol potassium)) tablet: effervescent, 1 tablet
Chlorvescent (potassium 14mmol) tablet: effervescent
Warfarin 1 mg tablet Warfarin (Marevan) 1 mg tablet
Warfarin (Coumadin) 1 mg tablet
Issues with Multum
• Methylprednisolone Primary is hidden• Created methylprednisolone acetate and methylprednisolone sodium succinate as C‐Dispensable Drug Names
• Created methylprednisolone 40 mg injection and methylprednisolone 40 mg/mL injectable suspension as M’s
• Issues with product assignment
Issues with Multum?
Not all the dosage forms commonly used in Australia available in the Multum codeset; about half of the dosage forms not matching
This might impact on medication reconciliation
• Unable to use some applications• iPad – good battery life of approx. 8 hours and lightweight• Fat finger; some situations require keyboard• To have both PharmNET and Powerchart open, must log in
first to PharmNet then Launch PowerChart; switch between these using two finger tap.
• PowerChart seems to ‘time out/close down’ on the iPadand then require relaunching and this can take a number of attempts.
• Cannot selectively choose drugs on iPad to enter comments (unlike a desktop by using Ctrl and clicking with the mouse).
• Will require a combination of products
iPAD
• Battery life approx. 3 hours only• Cannot log into external internet???• Doesn’t respond to finger, only pen• Pharmacist complained of eyestrain and
neck pain at the end of the day. OH&S issue....
• Too heavy• When battery goes flat, takes more than
2 mins to restart up. If restarted, takes more than 5 mins to reload.
• Slow to launch Cerner• Too difficult and slow to type in one letter
at a time using the keyboard and pen. Writing device not always recognise the handwriting.
• Nurse using for e‐administration
C‐Motion Tablet
Infection Control Issues
Achievements
• Realisation of a dream since 2002• Doctors are e‐prescribing and nurses e‐administration
• Improved communication• No fighting over drug charts• Medication audits
Early Experience
52%
47%
47%
38%
0% 10% 20% 30% 40% 50% 60%
Ceftriaxone (n=200)
Meropenem (n=19)
Pip‐Taz (n=85)
Vancomycin (n=68)
Restricted Antibiotics with Approvals
178 approvals in Dec and Jan25 in Jul and Aug,13 ceftriaxone,5 meropenem, 5 pip taz and 2 vanc
Missed Dose Audit
WARD CARIN YA GLR 1 GLR 2 MICH CRT SORR ENTO
GUNNA MATTA RRACS HILL VIEW
(R)
Jan-12 0.0% 0.5% 0.0% 0.2%Feb-12 0.2% 0.8% 0.4% 0.4% 0.7% 1.1% 2.2%Mar-12 0.6% 0.7% 0.6% 0.8% 0.6% 1.5%Apr-12 0.4% #DIV/0! 0.9% 0.4% 0.4% 2.8% 2.2% 2.5%May-12 0.0% 1.1% 0.4% 0.2% 1.0% 1.1% 1.2%Jun-12 0.0% 0.8% 0.4% 2.9% 1.8% 0.7%Jul-12 0.0% 0.0% 2.9% 0.3% 0.8% 0.0% 0.9% 0.2%Aug-12 0.8% 1.3% 0.2% 0.0% 0.8% 1.4% 0.3%Sep-12 0.8% 0.0% 0.0% 0.0% 2.1% 0.2%Oct-12 0.4% 0.0% 0.0% 0.0% 0.0% 1.8% 0.7%Nov-12 0.0% 0.0% 0.3% 0.0% 1.3% 0.5%Dec-12 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 1.4%
Pharmacy Department Survey
PositiveNegative
eMM is broader than just e‐prescribing
Conclusion
• The HealthSmart clinical system has been successfully implemented in acute and rehabilitation wards. Pharmacy staff are comfortable with using the system and there are early signs of medication safety benefits.